RUBELLA AND CONGENITAL RUBELLA SYNDROME CONTROL AND ELIMINATION — GLOBAL PROGRESS, 2000–2012

Monday, 26th of May 2014

[source]MMWR[|source]

Near elimination of rubella and CRS in the Americas proves that the tools exist to make elimination possible, and substantial progress is being made globally. However, gaps in surveillance limit the ability to monitor progress toward elimination, and recent outbreaks in Europe and Asia demonstrate the need for sustained, high-quality immunization programs. 

In this report, the authors USE Data from the WHO and United Nations Childrens Fund (UNICEF) Joint Reporting Form (JRF) to assess the changes in rubella and CRS control activities. Details on the progress since 2000 are presented and  accessible at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6248a3.htm

  

EDITORIAL NOTE

Following a period of steady but slow increases in rubella control, a new phase of accelerated rubella control and CRS prevention has begun, marked by the 2011 WHO position paper recommending a strategy to eliminate rubella and CRS, and emphasizing RCV introduction in all member states and the linkage of rubella to measles control activities. Programmatic integration of RCV into an existing measles schedule is straightforward, involving no increase in the number of injections or in cold-chain requirements with a combined measles-rubella vaccine, no change in age of vaccine administration, and minimal change in recording and reporting formats. Sustainable financing from government and partners is required to introduce and maintain routine rubella immunization activities and inclusion of RCV for all measles campaigns following introduction. The additional cost to include the rubella antigen with the measles vaccine is 0.199 to 0.309 U.S. dollars per dose.^¶ GAVI Alliance funding is available for eligible member states to support introduction; the funding supports a grant for introduction of RCV into the national routine immunization schedule and a wide-age-range RCV campaign. Nine member states applied for these funds in 2012.

For RCV introduction to succeed, decision makers need to identify rubella and CRS as a public health priority, provide sustainable support, and ensure adequate coverage. Suboptimal implementation of rubella control strategies might result in an increase in CRS cases; following years of low vaccine coverage and lower levels of rubella virus transmission, persons who would have been infected as children remain susceptible until they reach adolescence and adulthood, resulting in a potential increase in CRS cases, as seen in Greece (7). To prevent an increase in rubella and CRS, the preferred RCV introduction strategy is to first conduct a national wide-age-range campaign and then immediately introduce RCV into the routine immunization schedule. Postcampaign coverage surveys validate the campaign coverage and can identify potential gaps.

Activities to reach elimination goals in AMR and EUR have decreased the number of cases in 2012 relative to 2000. Improvements in surveillance have not been consistent between member states and WHO regions. Improved surveillance for rubella in AFR and SEAR has increased the number of rubella cases detected that previously would have been undetected. Strong reporting systems in WPR and EUR resulted in a greater proportion of the cases reported globally. In AMR, a clear decrease in rubella cases is associated with a decrease in CRS cases.

Outbreaks in EUR and WPR indicate that while control and elimination activities are ongoing, some member states within these regions are at risk for large outbreaks. Initiation of CRS control activities focused on vaccinating girls and women, which decreased rubella virus transmission but resulted in a large proportion of susceptible persons, especially males. A large population susceptible to rubella infection (primarily males) has a high risk for outbreak and transmission of rubella virus to unvaccinated pregnant women. Surveillance for rubella infection benefits from integration with measles surveillance systems, but additional effort is required to strengthen the system to ensure that febrile rash illness cases reported in pregnant women or their immediate contacts are fully investigated, including ascertaining pregnancy outcome. Surveillance to detect CRS is needed to monitor the impact of vaccination.

The difference between the 2012 global coverage with the first dose of MCV (83%) and RCV (43%) highlights the extent of the opportunity missed by the lack of integration of RCV with MCV. With a new phase of rubella control, member states should consider introducing or strengthening RCVs immunization activities and strengthening their existing rubella and CRS surveillance systems. The availability of technical expertise and financial resources from Measles Rubella Initiative partners, including the GAVI Alliance, provides a foundation to accelerate rubella control and CRS prevention activities globally. In addition, political commitment at the federal, provincial, and district levels is needed to reach the Measles Rubella Initiative and Global Vaccine Action Plan goal of elimination in five WHO regions by 2020.